Category Archives: vaguely boney

The Problem with Symbols

qwertyvsdvorak

symbols_edited-2It’s a good thing that Google doesn’t judge (I hope Google doesn’t judge), because I can’t imagine what a sentient search engine would think of me after the search terms I used to find my source images. It paints a very particular, but not accurate, picture.

Sometimes we have to touch on uncomfortable subjects, because uncomfortable things are happening.

A lot of people have objections to certain parts of the Pledge of Allegiance, primarily the “under God” part (and the fact that we don’t all enjoy equal access to liberty and justice), but I’ve long been troubled by the idea that we indoctrinate school children to pledge allegiance to a flag. Beyond the problem that the vast majority of elementary kids have zero idea what they’re actually saying, and are in any event too young to understand the implications of pledging themselves knowingly to any system, the concept of promising to…

View original post 619 more words


Substance Abuse in Behavioral Health Professionals

Abstract

Illicit drug and alcohol abuse by behavioral health professionals has been overlooked in psychological research. This researcher begins the analysis of substance abuse by behavioral health professionals by determining whether there is a significant difference in reported substance abuse between four categories of behavioral health professionals. The professional categories reviewed are social workers, licensed counselors, marriage and family therapists, and substance abuse counselors. Data was retrieved from the annually published Adverse Action Reports of the Arizona Board of Behavioral Health Examiners. The analysis uses a one-way ANOVA and Tukey’s post-hoc HSD test to determine the existence of a significant difference in population means of reported substance abuse by the different groups of behavioral health professionals. The researcher found that substance abuse counselors are reported for behaviors associated with substance abuse more frequently than other behavioral health professionals (F(3,18) = 4.739, p < .05). More research should be done to understand and mitigate this phenomenon.

Keywords: substance abuse, behavioral health professionals, social workers, licensed counselors, marriage and family therapists, substance abuse counselors

When people in Arizona need help recovering from their drug addiction, they are often sent to a licensed behavioral health professional to get that help. The professional they work with will probably be a Substance Abuse Counselor, someone specially trained to deal with the particular challenges of overcoming addiction. One would hope that the people hired to help those with substance abuse problems would not be in the midst of their own substance abuse problem. However, that cannot be counted on.

Defining substance abuse. The DSM-5 (2013) describes several criteria in the diagnosis of Substance Use Disorders, including but not limited to risky use of the substance in question. Behaviors that are indicative of dependency on either alcohol or illicit drugs, therefore, include those behaviors that put the individual at risk. These behaviors might be measured by their results. For example, one could count illicit drug or alcohol-related arrests, such as for driving while intoxicated, or non-criminal behaviors, such as testing positive in employment-based drug testing. Disciplinary reports could provide such a count. For that reason, this researcher defines substance abuse as the behaviors indicative of dependency on either alcohol or illicit drugs.

Current research. Although there are no studies specific to the problem of substance abuse by behavioral health professionals (BHPs) there are a number of disciplinary reports citing substance abuse policy infractions. A quick glance at the Adverse Actions Reports published in Arizona each year indicates that drugs and alcohol are problems for BHPs (Adverse Actions, 2014). However, while one can find studies of substance abuse and addiction problems in medical professionals (Domino, et al., 2005), similar studies of BHP have not happened or have not been published. Even those studies that have examined ethical challenges to the mental health field avoid substance abuse issues. A 1992 study by Pope and Vetter looked at twenty-three categories of ethical dilemmas faced by members of the American Psychological Association; Not one of those categories referenced substance abuse.

Of the behavioral health professions, only Substance Abuse Counselors (SAC) have been discussed in terms of their risk of substance abuse during their professional career. There is a history of organizations and private practices hiring recovered addicts (including recovered alcoholics) to fill that position (White, 2000). Their personal experience with addiction, it is argued, aids them as professionals because it allows for greater empathy with their clients (White, 2000). Opponents of the practice might question whether people with histories of substance abuse might increase their risk of relapse by repeatedly exposing themselves to the language and behaviors of substance abuse. One might question whether a behavioral health professional’s relapse could put their clients in danger of the same. White (2000) reported that there was a decreasing trend in the number of SAC who were themselves recovered addicts. However, his last cited estimate (62%) of SAC being recovered addicts was in 1997 (White, 2000). Currently, we do not know how many practicing SAC have a history of substance abuse, or how many have relapsed since being licensed as SAC. We also do not know whether SAC who are recovered addicts are at higher risk for substance abuse relapse than non-professionals or other BHP who have a history of substance addiction.

Indications of substance abuse. Studies on the general population give an idea of what some risk factors of substance abuse and relapse might be. The National Surveys on Drug Use and Health (Substance Abuse and Mental Health Services Administration, 2013) reported that 8.70% of Arizona residents over 26 years old, and 10.53% of Arizona residents over 18, experienced dependence on or abused alcohol or illicit drugs in 2010 and 2011. The population of behavioral health professionals in Arizona is a subset of the entire state population, so one might expect the rates of substance abuse to be similar in these populations. However, behavioral health professionals, as a group, are employed people who have self-selected into a career dedicated to helping others. This could be an indication of a tendency toward higher social responsibility, a personality trait inversely related to conscientiousness. Social responsibility combines at various life stages with social-environmental factors predict substance abuse, such that higher social responsibility predicts lower rates of substance abuse (Roberts & Bogg, 2004). Additionally, being employed increases social responsibility (Roberts & Bogg, 2004). Therefore we expect that BHP will have a lower substance abuse rate than their peers not in the same career category.

Sinha (2001) found stress to be a factor in relapses. As a group, BHP are subjected to vicarious traumas and lesser negative experiences, compassion fatigue, and general stress (Adams, Boscarino, & Figley, 2006). Additionally, behavioral health professionals are unlikely to seek out help when stress becomes overwhelming (Siebert & Siebert, 2007). These factors (high stress and reluctance to seek help) could increase their risk for substance abuse, particularly for those BHP with a history of substance abuse, for whom relapse is a possibility. If Substance Abuse Counselors (SAC) are in fact more likely to have a pre-professional history of substance abuse than other BHP, then one would expect them to also have a higher risk than other BHPs of substance abuse during their employment as behavioral health professionals.

Some questions concerning the challenges specific to substance abuse by behavioral health professionals have been described. It would be helpful to understand first whether certain behavioral health professionals have greater risk for substance abuse than others. The intention of this researcher is to determine whether there is a difference in reported substance abuse between the different behavioral health professions.

Method

Data Collection

This study used archival data, and the data was freely available on the websites of the reporting agencies, which were the Substance Abuse and Mental Health Services Administration (SAMHSA), a branch of the U.S. federal government, and the Arizona Board of Behavioral Health Examiners (ABBHE). Their websites are http://samhsa.gov/ and http://azbbhe.us/, respectively. The tally and computation of data was conducted in a Microsoft Excel file.

Archives

Data for this study was retrieved from Adverse Actions Reports published by the Arizona Board of Behavioral Health Examiners (ABBHE) over the past six years (from 2008 to 2013). ABBHE Adverse Action Reports are published annually by the ABBHE, and contain records of every disciplinary (adverse) action taken in response to violations by the licensed Arizona behavioral health professionals that occur in that year.

Participants

All behavioral health professionals who practiced in Arizona during the date range between 2008 and 2013, and who were reported for adverse action during that time, are included in ABBHE Adverse Action Reports. The ages, ethnicities and genders of these participants are unknown. These reports were used to collect a tally of citations of drug and alcohol misuse by social workers in Arizona, who are licensed and regulated by the ABBHE.

Procedure

In the ABBHE Adverse Action Reports, each reported professional is listed individually, and some professionals are listed as having multiple infractions in a single incident. Some incidences are listed more than once; in these cases, adverse action reports were generated at various stages of the investigation (e.g., a report might be generated at the time of allegation, and another report might be generated at the conclusion of the investigation). This researcher tallied the number of drug or alcohol-related infractions attributed to each licensure type each year, regardless of other infractions listed in a given incident, and only tallied once for each infraction, regardless of how many times the infraction was listed. Individuals whose application for initial licensure was denied due to drug or alcohol-related infractions were included in the tally. Drug or alcohol-related infractions tallied included self-reports of substance abuse, arrests for intoxication, and positive drug test results during employment screening.

There are four categories of behavioral health professionals licensed in Arizona. These include Social Workers, Licensed Counselors, Substance Abuse Counselors, and Marriage and Family Therapists (for a list of the licenses included in each category, see Table 1, Appendix).

Tallies for drug or alcohol-related infractions were compiled in the four groups, such that all infractions for SWs were in one group, LCs in another group, MFTs another group, and SACs in another group. Drug or alcohol-related infractions included reported arrests for drug or alcohol-related crimes (e.g., drunk driving arrests), self-reported drug or alcohol dependence, and positive results on employment-based drug tests.

Finally, the researcher contacted the ABBHE by phone, and requested the total numbers of behavioral health professionals licensed in Arizona for each of the years from 2008 to 2013, and the total population of each licensure group by year. That information was given to the researcher over the phone by a qualified representative of the ABBHE.

Design

This researcher used a one-way Analysis of Variance (ANOVA) and Tukey’s Honestly Significant Difference (HSD) Test to determine whether or not there is a significant difference in the four groups’ population means of substance abuse-related adverse action reports over six years, from 2008 to 2013. The one-way ANOVA was chosen because it allowed the comparison of more than two independent groups (four independent groups were tested). Tukey’s test was used because, if there were an honestly significant difference between the groups, it could be used to determine where the difference was. The independent variable is the licensure type of the behavioral health professionals who are monitored by the ABBHE. The four groups of license types described previously make up the four levels of the independent variable. The dependent variable is the rate of drug and alcohol misuse by individuals in each group, as reported in the Adverse Action reports. The proportions of individuals cited for substance abuse in each group, in each year, are the samples (see Table 2, Appendix).

Results

The null hypothesis is that there is no significant difference in the population means of substance abuse reported in the ABBHE Adverse Action Reports for each of the four major licensure types in Arizona. The alternative hypothesis is that there is, in fact, at least one significant difference in the population means of incidences reported in the ABBHE Adverse Action Reports for each of the four major licensure types. There was a significant difference in reported substance abuse among the Social Workers group (n = 6, M = .15%, SD = .08%), the Licensed Counselor group (n = 6, M = .13%, SD = .09%), the Marriage and Family Therapist group (n = 6, M = .13%, SD = .16%), and the Substance Abuse Counselor group (n = 6, M = .46%, SD = .21%) ( F(3,18) = 4.739, p < .05). Tukey’s HSD tests showed that the Social Workers group, Licensed Counselor group, and Marriage and Family Therapist group did not differ significantly from each other in substance abuse, but all three of those groups differed significantly from the Substance Abuse Counselor group (see Table 3, Appendix).

Discussion

This study was conducted to determine whether there is a difference in substance abuse by the different categories of behavioral health professionals, including Social Workers, Licensed Counselors, Marriage and Family Therapists, and Substance Abuse Counselors. Previous research implied a connection between substance abuse and stress (Sinha, 2001), and indicated that helping professionals such as BHP are subjected to high stress (Adams, Boscarino & Figley, 2006) but have difficulties reaching out for help (Siebert & Siebert, 2007). Further, previous research indicated that many Substance Abuse Counselors are recovered, or recovering, from substance abuse addictions and thus are at risk of relapse (White, 2000), while the same has not been indicated for other BHP. Therefore, this researcher expected to find that Substance Abuse Counselors do have a higher rate of substance abuse than do other BHP. This expectation was met.

This study was limited because it only included those BHP who were reported through ABBHE channels were included in the tally of substance abuse-related behavior. It is unknown how many BHP might behave similarly, but due to circumstance or other unidentified factors, might not have been reported for disciplinary action. A review of disciplinary actions by professional psychology boards found that many infractions are never reported (Van Horne, 2004). It is possible that behavioral health professional boards have similar inconsistencies. This study did not examine this possibility.

A potential confound of this study is that some of those reported in the Adverse Action Reports for substance abuse behaviors were applicants, as opposed to being fully licensed BHP. It is unknown whether the professionals would be more or less likely to engage in this behavior based on their status as applicants or licensees. Other potential confounds include the ages, sexes, genders, and career longevity of the BHP. None of these demographics are reported in the Adverse Action Reports, so differences based on these are unknown.

A more comprehensive study should include demographic information and a broader population. While this study included all BHP in the state of Arizona, it would be beneficial to include comparable data from other states. In addition to increasing the sample size and giving more depth to the study, this might serve to point out regional differences, which might be indicative of the relative successes of state policies on substance abuse support for BHP.

Future research should branch out from the understanding that Substance Abuse Counselors could be more likely than other behavioral health professionals to struggle with substance abuse. Studies that seek to understand the relative effectiveness of various state policies on substance abuse support for behavioral health professional should be considered, as should studies that question the risk factors for substance abuse in behavioral health professionals, such as compassion fatigue or personality types. These studies should focus particularly on Substance Abuse Counselors. It would also be beneficial to determine whether Substance Abuse Counselors who do have a history of substance addiction are more or less likely to relapse than people who have similar histories of addiction but are not behavioral health professionals.

Conclusion

It is important that people who seek help for substance use disorders are able to get help from a professional who is not at risk of succumbing to the same disorder. It is just as important that behavioral health professionals have the support required to assist clients. Substance Abuse Counselors with a history of substance abuse are common in the field, and they are attempting to help a population that does not necessarily receive a lot of empathy from others. These professionals have the empathy, they are willing to help, and they are simultaneously trying to help themselves become better people. Determining the best course of action the rest of the population can take to aid these professionals in these goals should be a priority.

 

References

Adams, R. E., Boscarino, J. A., & Figley, C. R. (2006). Compassion fatigue and psychological distress among social workers: A validation study. American Journal of Orthopsychiatry, 76(1), 103-108.

Adverse Actions. (n.d.) About Us. Retrieved January 29, 2014, from http://azbbhe.us/adverse-actions

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed., pp. 483-589). Substance-Related Disorders. Washington, D.C.: Author.

Domino, K. B. (2005). Risk factors for relapse in health care professionals with substance use disorders. The Journal of the American Medical Association, 293(12), 1453-1460.

Pope, K. S., & Vetter, V. A. (1992). Ethical dilemmas encountered by members of the American Psychological Association: A national survey. American Psychologist, 47(3), 397-411.

Roberts, B. W., & Bogg, T. (2004). A longitudinal study of the relationships between conscientiousness and the social- environmental factors and substance-use behaviors that influence health. Journal of Personality, 72(2), 325-354.

Sinha, R. (2001). How does stress increase risk of drug abuse and relapse? Psychopharmacology, 158(4), 343-359.

Substance Abuse and Mental Health Services Administration. (2013). 2010-2011 NSDUH State estimates of substance use and mental disorders. Retrieved February 27, 2014, from http://samhsa.gov/data/NSDUH/2k11State/NSDUHsae2011/Index.aspx

Van Horne, B. A. (2004). Psychology licensing board disciplinary actions: The realities. Professional Psychology: Research and Practice, 35(2), 170-178.

White, W. L. (2000). The history of recovered people as wounded healers: II. The era of professionalization and specialization. Alcoholism Treatment Quarterly, 18(2), 1-25.

 

Appendix

 ImageImageImage

Image


Toward a Theory of Gender

Evolution has shaped our species’ cognitive developmental stages, and therefore the process by which we develop personalities and our core gender identity development. The assumptions I’m making here are that human personality development is a product of our cognitive development, and that our core gender identity is an aspect of human personality. The remaining question  I’ll address here: why does individual gender identity develop as it does?

Much academic energy has been spent in discerning the how’s and why’s of gender identity, and how gender identity affects, or is affected by, our personality development (Bem, 1981;  Buss, 1995; Erikson, 1993; Feingold, 1994; Freud, 1905/1991;  Harter, 1998; Kohlberg, 1966, and more). Very little of that – perhaps none – has encompassed all genders. Heteronormative genders are addressed comprehensively, but non-heteronormative genders are left unexamined, assumed to be pathologies. This exclusion and its unstated guiding assumption leave these theories short of their goals.  Logically, any explanation of heteronormative gender identities must also explain non-heteronormative gender identities – even if that means explaining how the assumed pathology of non-heteronormativity developed. I will argue, though, that non-heteronormative gender might not be pathological; the labeling of it as pathological is cultural, rather than scientific, and is not evidence-based. Instead, an inclusive, unified theory of gender development can, and should, be found.

Modern gender theory began as many psychological studies have, in the work of Sigmund Freud, particularly his Three Essays on the Theory of Sexuality (1905/1991). Of course, he did not address gender as separate from physical characteristics; gender was a synonym for sex and an indicator for sexuality. These three things were inseparable, and any deviation from heteronormativity was considered a mental illness. Thus healthy sexuality was tied unequivocally to an individual’s primary sex characteristic (namely, their genitalia), and it was taken for granted that one led to the other in any natural progression. Freud wrote of sexuality as though it were a given, based on the developing individual’s primary sex characteristics. Indeed, that was an unquestioned assumption – almost a cultural foreclosure – applied to research by Freud and a legion of following psychologists. Freud, and arguably western culture in general, viewed gender as a binary: the only options were male and female, anything else was a malady or perversion.

Looking at Freud’s theory of sexual identity, we must set aside his linguistic conflation of sex and gender, and view it as a theory gender identity development; this both captures the essential meaning of his theory and makes that theory useful to our discussion. In Freud’s words:

As we all know, it is not until puberty that the sharp distinction is established between the masculine and the feminine characters. From that time on, this contrast has a more decisive influence than any other upon the shaping of human life. It is true that the masculine and feminine dispositions are already easily recognizable in childhood (Freud, 1905/1991).

If we accept “masculine” and “feminine” as gender descriptors, rather than necessary personality traits dictated by primary sex characteristics’ physical appearance, then we see that Freud is suggesting that gender begins quite early in childhood and is probably innate, but develops clearer distinctions with the onset of puberty. If puberty is a guiding event in gender development, then it seems there is a biological component to that development beyond the obvious primary sex characteristics, however tied they are to the biochemistry of puberty. However, Freud still argued that children modeled their gendered behavior after their parents, thus supporting the idea that gender, in some ways, is learned.

Whether later psychologists agreed with Freud or not, his language (which was perhaps a shared language of western culture) colored their perspective and guided their research. Erik Erikson agreed, partially; he theorized that the development of a core gender identity began during adolescence, in what he terms the “identity versus role confusion” stage. He disagreed that adolescents mirrored their parents exclusively to achieve gender identity. Instead, Erikson thought that peers were the greater influence during this stage (1993). Erikson’s theory set the stage for Susan Harter’s conceptualization of the social interactionist perspective, which described the development of identity (including gender identity) as a process of acting out various cultural role-templates in public situations, much the way one might try on clothing to find the right fit (1998). Erikson and Harter, and many others, shared the belief – stated or not – that gender was external, which youths developed primarily by watching the people around them. Thus, gender was not basically innate.

Lawrence Kohlberg (1966) brought the concept of internally-derived gender back to the table with his cognitive-developmental model; he also thought that gender solidified around seven years of age, much earlier than his predecessors had argued. Kohlberg stated that children were capable of recognizing gender differences by age three, and began to understand “gender consistency” between the ages of four and seven years. It followed, according to Kohlberg, that children would naturally want to learn how to behave as their assigned gender. Thus gender identity was internal, but the social roles played by each gender were external.

In the early 1980s, Sandra Bem brought these opposing viewpoints together in her gender-schema theory, blending cognitive and social elements of the process of core gender identity development (1981). The sources of gender, then, were both internal and external – we’re back to Freud, but without the automatic gender assignment based on anatomy. Bem may have been the first prominent gender theorist whose theory didn’t automatically assume that individuals would choose male or female, depending on their genitals; the theory avoids that assumption by describing the process of gender development as separate from but related to sex-typing, rather than using the two concepts synonymously.

Evolutionary psychology has offered modern psychologists another view of gender. Instead of attempting to describe gender without knowing its origins, evolutionary psychologists attempt to determine why we develop gender identities as a species, which in fact gives us a description of gender development in individuals. David Buss gives a concise evaluation of the evolutionary perspective of gender in Psychological Sex Differences: Origins Through Sexual Selection (1995). The sociocultural differences between males and females within a heteronormative model developed just as male and female physical differences in any secondary sex characteristic did, through sexual selection. In fact, though he doesn’t specify, his definition does categorized gender as a secondary sex characteristic. It’s notable too, that this perspective of gender uses gender identity not as a whole component of personality, but as a measurement of relative trait strength or frequency; it could be said that each trait which could be used to quantify the gendered-ness of an individual could be measured against zero, with ‘males’ scoring higher in specific traits, and ‘females’ in others. Buss never tells us how he thinks non-binary gender fits into this, but his theory leaves space for additional information and hypothesis.

If these traits which define our genders are in fact explained by evolutionary pressures and are an adaptation through sexual selection, and they are measurable by degrees, then we might best view gender as a wide continuum, with “male” and “female” on opposite ends. I would predict, were we to do this, that given the variations in evolutionary pressures over the wide geography and history of humans, most individuals in today’s more blended world culture would vary from the absolute, thus falling somewhere between those ends, rather than on the ends. Additionally, were such a continuum graphed, there would be room for and instances of gender that deviate from the culturally-associated sex. In fact, if the necessity for gender bifurcation becomes less – given our species’ progressive dominance over the environmental factors which create evolutionary pressures – we may see an increased variation in gender expression among our global population.

From 2000 to 2013, the American Psychological Association, publishers of the Diagnostic and statistical manual of mental disorders (DSM-IV-TR; 2000) defined Gender Identity Disorder in a way that included transgender self-identification regardless of the relative happiness of the patient with that status. While some transgendered individuals certainly do experience distress over the non-conformity of their gender and their sex, that isn’t the case for all transgendered individuals. By the DSM-IV-TR’s definition, “Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual” (p. xxi-xxii). Thus people who are transgendered and well-adjusted (not in conflict with society) were described in the definition of Gender Identity Disorder, but not in the definition of a basic pathology. That specific pattern of inclusion/exclusion indicates that transgendered individuals who were not in distress could have been considered mentally ill by the  American Psychological Association (APA). The implication was that cultural assignation of gender took precedence over an individual’s internal understanding of gender, such that a person who believed their own gender to be in opposition with the gender assigned to them were automatically pathological.

Gender identity is being reconsidered by the APA. The fifth edition of the Diagnostic and statistical manual of mental disorders (DSM-5; 2013) stresses that individuals must show distress over their gender to be diagnosed with Gender Dysphoria, although the central attribute of diagnosis is still the difference between a transgender person’s assigned gender and their gender identity. This seems indicative of a shift in the perception of gender. In recent years, research concerning the nature of gender has identified physical aspects to gender identity that separate gender from sex. We know now, for example, that sex is not determined merely the absence or presence of certain gonadal hormones, and that there are neurobiological and anatomical differences among the sexes that result from chromosomal differences rather than hormonal differences (Arnold, 2003; Ngun, Ghahramani, Sanchez, Bocklandt & Vilain, 2011). Researchers have also identified neurobiological structures that could be linked to gender identity and others are seeking out various potential genetic origins of gender (Ngun et al., 2011).

As research in this area progresses, the results may challenge us to further consider separating the distress caused by external, cultural pressures of gender from internal, apriori psychological distress. Perhaps those who present as having distress over their gender identity should be evaluated in light of determining whether their distress is a natural result of the cultural difficulty of living as a transgender person in a world that does not accept transgender people.

As we come to understand that gender differentiation is accompanied by differences in genetics and neuroanatomy, we must look more closely at the components of gender. Just as we once had to learn to split gender and sex, we now must separate the development of gender expression from from the biological development of gender identity. The discussion so far in this paper has conflated gender expression and gender identity. When we separate these aspects of gender, we see that they result from very different things. Gender identity is apparently related to differences in neurobiology, while gender expression remains mysterious, seeming to be influenced primarily by less empirically measurable variables, such as personality and social mores.

We are moving toward an understanding of the biological components that shape individual gender identity. This will be a key component in understanding gender expression, as it provides the motivation for the expression of gender that is not socially copacetic. For a transgender person, gender expression – because it conflicts with social expectations – becomes the battleground on which they fight for their right to be their identified gender. That battleground then becomes the source of psychological distress that the APA has identified as a key to diagnosing Gender Dysphoria. If genes and neurobiology shape gender, then it follows that any person can be whatever their gender identity is without that identity being considered pathological. The clarification of gender identity development will open the door to understanding gender expression development.

 

 

References

Arnold, A. P. (2003). The gender of the voice within: the neural origin of sex differences in the brain. Current Opinion in Neurobiology, 13(6), 759-764.

Bem, S. L. (1981). Gender Schema Theory: a Cognitive account of sex typing. Psychological Review, 88(4), 354-364. Retrieved November 13, 2011, from the Cornell University database.

Buss, D. (1995). Psychological Sex Differences: Origins Through Sexual Selection. American Psychologist, 50(30), 164-168.

Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). (2013). Washington, D.C.: American Psychiatric Association.

Diagnostic and statistical manual of mental disorders: DSM-IV-TR. (4th ed.). (2000). Washington, DC: American Psychiatric Association.

Erikson, E. H. (1993). Childhood and society. New York: Norton.

Feingold, A. (1994). Gender Differences In Personality: A Meta-analysis.. Psychological Bulletin, 116(3), 429-456.

Freud, S. (1991). On sexuality: three essays on the theory of sexuality. London: Penguin Books. (Original work published 1905)

Harter, S. (1998). The development of self-representations. Handbook of Child Psychology (5th ed., pp. 553-617). New York: Wiley.

Kohlberg, L. (1966). A cognitive-developmental analysis of children’s sex-role concepts and attitudes. The development of sex differences (p. 0). Stanford, CA: Stanford University Press.

Ngun, T. C., Ghahramani, N., Sánchez, F. J., Bocklandt, S., & Vilain, E. (2011). The genetics of sex differences in brain and behavior. Frontiers in Neuroendocrinology, 32(2), 227-246.